Main Article
Pectoralis Major Myocutaneous Flap Reconstruction in Buccal Carcinoma
- Our Experience in ENT Department Medical College & Hospital, Kolkata
Dr. Shoham Banerjee*, Dr. Sabyasachi Barik*, Dr. Sohag Kundu**, Dr. Bhaskar Ghosh***,
Prof. S. Mukhopadhyay****
Pectoralis major myocutaneous flap is regarded as the
workhorse for reconstruction in many head and neck
1
surgeries and was first described by Ariyan in late 1970s .
Mc Gregor and Reed in 1970 described the blood supply to
1
skin flaps as axial or random . PMMC has both axial blood
supply (distinct arteriovenous circulation along its long
axis) in its proximal part as well as random supply
(communicating vessels in dermal subdermal plexus) in the
distal part beyond the pectoral branches of thoracoacromial
2
artery when skin and underlying rectus fascia are included .
Pectoralis major being a thick fan shaped muscle has origins
from medial half of clavicle, sternocostal from manubrium
and body of sternum with second to sixth costal cartilage and
from rectus fascia. It is inserted into the crest of greater
tuberosity of humerus. The fibers are directed from
horizontal to oblique. The nerve supply is from lateral
pectoral nerve which arises from the lateral cord of brachial
plexus and is located medially and from medial pectoral
nerve which is located laterally and originates from medial
3
cord of brachial plexus . Lateral pectoral nerve is closely
related to pectoral branch of the thoracoacromian artery and
forms the neurovascular bundle. The arterial supply is from
the pectoral branch of thoracoacromian artery, the lateral
thoracic artery from axillary artery and from superior
4
thoracic artery to a lesser extent . The pectoral branch of
thoracoacromian artery is the main supply and it lies between
pectoralis major and minor muscle, engulfed in the fascia
running inferiorly along the oblique fibers of pectoralis major
muscle upto the fifth or sixth rib being medial to the nipple.
Blood supply to
pectoralis major muscle
* Junior Resident
** RMO cum Clinical Tutor
*** Assistant Professor
**** Professor & Head
Department of ENT, Medical College, Kolkata
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Salient points in operative steps to harvest PMMC flap:
Outline the course of thoracoacromian artery (it lies
medial to the line joining the acromianprocess to the
xiphoid process and a perpendicular to it drawn from the
midportion of clavicle) and the size and configuration of
skin paddle (it should lie between lateral edge of sternum
medially and nipple laterally) and muscle required to
cover the defect. If deltopectoral flap is additionally
required it has to be elevated first from its distal portion on
the medial aspect of the thoracoacromian artery5. Lateral
thoracic artery can be preserved by dividing the humeral
head of pectoralis major muscle. The initial incision for the
flap is along the lateral border of the outlined skin for the
pectoralis major flap and it is carried down upto the
muscle. After identification of the vascular pedicle the
elevation is done deep to the fascia above the pectoralis
minor muscle. The required skin and the subcutaneous
tissue is incised and sutured with the superficial fibers of
the underlying muscle. The rest of the skin and the
subcutaneous tissue are dissected free from the muscle
with haemostasis as required. The pectoralis major and its
underlying fascia along with vascular pedicle are lifted
upwards keeping the pedicle under vision after dividing
the inferior attachments from rib and rectus sheath6. The
nerves may be preserved if the muscle bulk is required in
the post operative period. The medial half of clavicle may
be resected if additional length is required and it also helps
to fill the gap in supraclavicular region in radical neck
dissection cases and the vascular pedicle is not
compressed by the clavicle. The flap may also be placed
anterior to the clavicle passing underneath the skin tunnel.
The lateral dissection is done as per mobilization required
but the vascular pedicle must be intact. Excessive twisting
of PMMC is avoided and the skin margins are sutured to
the defect site. Two separate suction drains are given, in
the neck and in the anterior chest wall. The chest wall may
be closed by suture after mobilization of the surrounding
skin or a split skin graft may be used in large defect.
Clindamycin is preferred in post operative period as it
binds to leucocytes and reaches to the demarcated end of
the flap as compared to cephalosporins .
11

Diagrammatic
representation of
PMMC under skin
tunnel
Complications : Loss of the flap in the distal aspect,
infection, obscuring early recurrence of disease, limited use
of ipsilateral upper extremity when used in cases where
spinal accessory nerve has been sacrificed and hair growth
over the flap are the most common reported complications.
PMMC flap can be used as a single paddle, double paddle,
side by side paddle, large skin paddle and inframammary
paddle and it can be combined with deltopectoral flap as
per requirement.
Buccal carcinoma is the most common site of oral
carcinoma in south East Asia with betel quid
consumption, smoking and alcohol being strong
associating factors for carcinoma development.
Study Period, Area
The study was conducted in Medical College and
Hospital, Kolkata from June 2009 to September 2012.The
cases were selected from the patients attending the out
patients department of ENT during this period.
There were 14 patients all male, mean age of presentation
being 46 years (36-58 years) with squamous cell carcinoma
of cheek involving the buccal mucosa. Of the 8 patients
who had external skin involvement, 3 had margins <lcm
from mandible and 3 had mandibular involvement. In the
remaining 6 patients there was no skin involvement but 2
of them had mandibular invasion by the tumour, the rest
had a margin >lcm from the mandible. 10 patients were
T4a while the rest 4 were in T3. 10 of them had N2b and the
rest 4 had Nl nodal status. 4 had diabetes and 5 had
hypertension as co morbidity. Histopathologically they
were in moderately to poorly differentiated infiltrating
squamous cell carcinomas.
Bipaddle PMMC flap was done in 1 patient, 4 had PMMC
with Deltopectoral flap where 2 was diabetic and rest had
single paddle PMMC with skin grafting on inner aspect
where 2 were diabetic.
Segmental mandibulectomy was done in 3 patients, 3 had
marginal mandibulectomy and hemimandibulectomy was
done in 2 cases. In all the cases during neck dissection
sternocleidomastoid was deliberately cut to accommodate
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the PMMC flap and for 3 cases we had to cut the spinal
accessory nerve as it was not possible to save it during
resection. IJV was preserved in all the cases. The neck
dissection was done with the help of monopolar diathermy
except the facial vessels which were ligated. Post operative
radiotherapy was given in all cases after discharge.
Follow up
There was one incidence of necrosis of PMMC and DP flap
in a diabetic patient and gaping in PPMC flap in two
diabetic patients. Rest of the cases had good post operative
outcome in a follow up of an average of 3 years. Restricted
mobility of ipsilateral upper limb was noted in cases
where the spinal accessory nerve was sacrificed.
Mrnd type 2 with left sided squamous cell ca
hemimandibulectomy right cheek with skin
involvement
PMMC flap harvested and PMMC & DP flap placed
placed under skin tunnel with drains
Conclusion : PMMC is an excellent distal flap for closure
of defects in neck and lower face. It doesn't give way easily
even in post radiotherapy period. Diabetics have a
tendency for flap necrosis.
References
1. Atlas of head and neck surgery,4th edition, John M. Lore&
Jesus E. Medina; page 402
2. Ariyan S, Cuono CB: Myocutaneousflaps for head and neck
reconstruction. Head neck surgery 2:321-345,1980
3. Atlas of head and neck surgery,4lh edition, John M. Lore&
Jesus E. Medina; page 405
4. Atlas of head and neck surgery,4th edition, John M. Lore&
Jesus E. Medina; page 406
5. Rob& Smith: Operative surgery head and neck part 2 4th
edition; page 381-382
6. Stell & Maran: textbook of head and neck surgery and
oncology,5th edition; page 939-948
7. Atlas of head and neck surgery,4th edition, John M. Lore&
Jesus E. Medina; page 404
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